It can be frustrating and disheartening to learn that your workers’ comp claim has been denied. After all, you might be hurting, facing medical bills, and unable to work. Unfortunately, this scenario is an all too common for injured workers.
The good news, however, is that you have the right to appeal a denial. And your chances of receiving a settlement or award get better when you challenge the initial decision. See the results of our survey on appealing denied workers’ comp claims, and read on to learn how the appeals process works and what you can do to help your case.
Contact the Insurance Company After a Denial
Your employer’s insurance company will typically make the initial decision on your workers’ comp claim. After you receive a denial notice, your first step should be to contact the insurance company and ask why it rejected your claim. If the problem was missing information or paperwork that wasn’t filled out correctly, you might be allowed to fix the mistake and have your claim reconsidered.
Aside from technical problems, there are several common reasons for denying workers’ comp claims. Whatever the justification, you can usually ask the insurance company to reconsider its decision. This might be worthwhile if you have additional facts or documents to support your claim. For instance, if the insurer believes the real cause of your current medical condition is a previous sports injury, you may be able to provide medical records showing that you needed only minimal, short-term treatment for that old injury.
File the Appeal
If you can’t work things out with the insurance company, you will typically need to file a formal claim or appeal. It's important to keep in mind that there are strict deadlines for appealing workers’ comp denials, which vary from state to state. In many states, you have one year or longer to appeal. In California, for instance, you generally must file an “application for adjudication of claim” within a year after you were hurt or you last received medical or temporary disability benefits. In other states, the timeline may be as short as a few weeks or months. For example, the time for filing an appeal in Ohio is generally only 14 days after you receive the denial notice.
It’s also important to pay attention to the proper procedures for filing an appeal in your state. In some states, this might be as simple as sending a letter to your state’s workers’ compensation agency. In other states, you need to fill out forms and attach certain documents. You could lose your right to benefits if you don’t follow the rules. Read the denial notice from the insurance company carefully. Usually, it will explain the process and the timeframe for taking action. (For more information on the appeal procedures in your state, see this state-specific information for workers’ compensation.)
In many states, you may have the option of participating in mediation before your hearing takes place. Some states require mediation, at least in most cases. In Pennsylvania, for instance, you’ll be scheduled for mediation unless the judge believes it would be futile.
At mediation, you and the insurance company will each get a chance to present your case to a mediator—a neutral third party who tries to help you resolve the dispute. This usually happens through informal conversations in a conference room. Although mediation does not require formal arguments or follow procedural rules, it can be very helpful to have an attorney representing you at this stage. A lawyer can help you figure out what arguments are the most persuasive and help you evaluate settlement offers from the insurance company.
If you and the insurance company come to an agreement at mediation, the agreement will be formalized in writing, and a workers’ comp judge will usually review it. If you cannot agree to a settlement, however, you will continue on to the next step.
In most states, the next step is a workers’ compensation hearing. Before the hearing actually takes place, however, you may attend an informal conference with the workers’ comp judge. Generally, you and the insurance company will also share evidence, such as transcripts of depositions and medical records, including reports from your independent medical exams.
Although a workers’ comp hearing is less formal than a trial, it does have some similarities. For example, both sides make legal arguments and present evidence, including testimony from witnesses. There are also certain procedural rules that must be followed, and a workers’ comp judge (or other official) will preside over the hearing.
To succeed at the hearing, you will need to convince the workers’ comp judge that the initial denial was wrong. The evidence you should present will depend on your particular case and the reason for the denial. (Learn more about what to expect at a workers’ comp hearing.)
Although you have the right to represent yourself at the hearing, it’s highly recommended that you have an attorney at this stage. A qualified workers’ comp lawyer will be able to craft persuasive legal arguments, present relevant evidence, follow procedural rules, and present your case in the best light possible. And because the insurance company will undoubtedly have legal representation, having your own lawyer will help even the scales.
If you’re unsuccessful at your hearing, many states allow you to file a second administrative appeal. The workers’ compensation appeals board, or a select panel of workers’ comp judges, will usually handle this appeal. In most cases, this is not an opportunity to present evidence again. Instead, it's your chance to explain why the original hearing officer’s decision was wrong, based on the evidence presented at the hearing. You should know that the insurance company may also appeal if it’s unhappy with the decision of the workers’ comp judge.
If you don’t win the administrative appeal, the final step in most states is to appeal through the state court system. In many states, your case will proceed like any other lawsuit and will eventually be decided by a judge or a jury. During the process, you will have to follow all of the rules of procedure and evidence in your state, which can be quite complicated. If you haven’t done so already, you should consult with a lawyer before filing an appeal through state court. (Learn how to select the best workers’ comp attorney for your case.)